Including Health Economics in Your Specific Aims and Approach

Ruanne V Barnabas, MD, DPhilHealth Economics Impact Study Team (HEIST)Center for AIDS Research (CFAR)

Outline

• Background• Specific Aims• Approach• Contact details

What cost-effectiveness research question are you interested in?

• Questions the reviewers would like answered in your grant application:

• What is:▫ the intervention?▫ the comparator?

• What outcome measures are appropriate?• How will you evaluate intervention benefits?• How will you measure program costs?• Will you adjust for changes in direct medical costs

resulting from the intervention?• Can you sketch a model/tree that portrays the

consequences of the intervention and its comparator?

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Introduction

• Start working with a HEIST member early in your grant application process

• Send Ruanne an email request team notified matched with a health economist/modeler depending on the question

• Think about whether you want to add costing, modeling or cost-effectiveness analyses to your application

• Do you need a behavior economist?• We can provide general advice or help with grant

writing

The Process* – applies to health economic analyses too• A good idea• A good institutional fit• Assemble a winning team• Match the idea to a sponsor• Read the Guidelines

• Contact the sponsor• Plan in detail• Develop the budget from the

detailed plan• Read the guidelines again with

narrative in mind• Be persistent - revise and resubmit

*Adapted from the NIH grant writing slides

More Questions to Ask

• Does the funding agency share your goals?• Is the funding agency interested in the same

populations?• Has the funding agency funded projects similar to yours?• Have they made awards to institutions similar to ours?• Does the agency require matching?• When will the award be made?

Call the Program Officer

▫ Health economic analyses are not always required/helpful▫ Who will use the results of the economic analysis?

A Grant is not an IdeaIt is a Plan

Parts of a Grant Application• Cover Page• Table of Contents• Abstract• Problem or Needs Statement• Goals and Objectives• Methodology• Quality of Key Personnel

• Evaluation• Dissemination• References Cited• Budget & Narrative• Vitae• Appendices• Forms, Certifications and

Assurances

Specific aims

• The specific aims state the essence of the proposed work in terms of what will be accomplished.

• Break the aim down to specific measurable pieces, the outcomes of which can be measured to determine actual accomplishments.

Specific aims

• Objectives discuss who is going to do what, whenthey will do it, and how it will be measured.

• Discuss desired end results of the project.• But not how those results will be accomplished.• They are action oriented and often begin with a verb.• Arrange them in priority order.• In a research proposal the objectives are the

hypotheses, they are less specific, but reinforce that the project is conceptually sound.

Specific aims• Show that you understand

the problem• Demonstrate that this is an

important problem to solve, also at regional and national level

• Clearly describe the aspects of the problem that your project will address, and what gaps this will fill

• Describe the theoretical or conceptual basis for your project and your knowledge of the issues surrounding your proposed project

• Include statistical data, if appropriate

• Demonstrate that your approach is creative or innovative

• Describe how this project fits into the already existing goals of the organization

Specific aims: Questions to Ask

• What significant needs are you trying to meet?

• What is the current status of the needs?

• Will this project help meet the need?

• What really needs to be done?

• What services will be delivered? To whom? By whom?

• Is it possible to make some impact on the problem?

• What gaps exist in the knowledge base?

• What does the literature say about the significance of the problem, at a local, state, regional, national level?

• Is there evidence that this project will lead to other significant studies?

• What previous work has been done to meet this need? Was it effective?

• What will be the impact of this study?

What cost-effectiveness research question are you interested in?

• Questions the reviewers would like answered in your grant application:

• What is:▫ the intervention?▫ the comparator?

• What outcome measures are appropriate?• How will you evaluate intervention benefits?• How will you measure program costs?• Will you adjust for changes in direct medical costs

resulting from the intervention?• Can you sketch a model/tree that portrays the

consequences of the intervention and its comparator?

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Motivating example: What is the most cost-effective method to promote voluntary male circumcision in Uganda (Linkages study)?

• Target population: HIV- uncircumcised men ages 18-49

• Options: 1. Healthcare worker MC promotion at time of HIV test2. Healthcare worker promotion plus SMS follow-up

encouraging MC within 1 month 3. Healthcare worker promotion plus follow-up at 1 and

2 months to encourage MC and address barriers to uptake

• Option 3 may be the most effective but it is likely to incur the most costs.

Let’s write a specific aim:

• Aim 1▫ To determine the uptake of MC referral by 3

months among HIV-uninfected men 16-49 years of age, with either promotion at point of HIV testing, SMS follow-up or lay-counselor follow-up visits

• Aim 2▫ …

Pairing health economic aim with effectiveness aim• Aim 2:▫ To evaluate the (i) incremental cost, by MC

demand stimulation strategy, and the (ii) incremental cost-effectiveness, by MC demand stimulation strategy, per HIV infection and HIV related death averted.

Pairing health economic aim with effectiveness aim• Aim 1: ▫ To determine the uptake of MC referral by 3

months among HIV-uninfected men 16-49 years of age, with either promotion at point of HIV testing, SMS follow-up or lay-counsellor follow-up visits

• Aim 2:• To evaluate the (i) incremental cost, by MC demand

stimulation strategy, and the (ii) incremental cost-effectiveness, by MC demand stimulation strategy, per HIV infection and HIV related death averted.

• Clearly link effectiveness and health economic aim

Pairing health economic aim with effectiveness aim• To evaluate the (i) incremental cost, by MC

demand stimulation strategy, and the (ii) incremental cost-effectiveness, by MC demand stimulation strategy, per HIV infection and HIV related death averted.

• Can also include hypothesis:▫ Demand creation strategies will be cost-effective

per HIV infection and HIV-related death averted• Can also include brief approach▫ Costing, modeling, and cost-effectiveness

Pairing health economic aim with effectiveness aim• To evaluate the (i) incremental cost, by MC

demand stimulation strategy, and the (ii) incremental cost-effectiveness, by MC demand stimulation strategy, per HIV infection and HIV related death averted.

• Key feature:▫ Incremental cost – measured in the study▫ Cost-effectiveness – modeling to measure health

outcomes▫ ICER – combining costs and cost-effectiveness

What cost-effectiveness research question are you interested in?

• Questions the reviewers would like answered in your grant application:

• What is:▫ the intervention?▫ the comparator?

• What outcome measures are appropriate?• How will you evaluate intervention benefits?• How will you measure program costs?• Will you adjust for changes in direct medical costs

resulting from the intervention?• Can you sketch a model/tree that portrays the

consequences of the intervention and its comparator?▫ Details go in the approach section

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Describe where the data will come from and how the analysis will be done for Aim 2:

Describe where the data will come from and how the analysis will be done for Aim 2:

• Effectiveness of each intervention • Prevalence of HIV in Uganda, current uptake of

MC, ART coverage• Sexual behavior, age-structure of the population,

background mortality rate.• Costs of interventions and standard of care (ie

MC procedure, HIV testing, ART, hospitalization)

• Costs averted by preventing future cases of HIV through MC

Data sources: • Ongoing study data

• Current clinical trial or cohort study• Published peer-reviewed data

• Specific clinical trial or cohort (single study evidence)• Literature reviews (e.g. Pubmed): Examine evidence from

multiple studies• Meta-analyses: pooled evidence from multiple studies• Systematic reviews: highest quality reviews or meta analyses

• Cochrane Collaboration, Cochrane library• Unpublished data

• In country expert opinion• Ministry of Health

• NGO reports• UNAIDS, WHO life tables, WHO-CHOICE website,

International drug price indicator Guide, Clinton Health Access Initiative (ART prices)

Published sources:• Costs of MC, HIV/AIDS treatment, and OIs

• HIV transmission rates

• Disability adjusted life years for HIV/AIDS

Ongoing study:

• Randomized clinical trial • Linkages Study—3 arms of MC promotion• Trial will be used to estimate uptake (efficacy) and

incremental costs of each intervention

• Advantages of using a prospective trial –describe these in the approach section:• Detailed costs—not normally recorded• Time and motion studies—capture staff time spent on

different aspects of intervention• Identify areas of inefficiency (wasted resources or time) &

modify protocol• First-hand assessment of trial quality• Quick turnaround of CEA for policymakers

Limitations of data sources:• Generalizability

• Population chosen for cohort, self-selection into clinical trial• Scale-up

• Time frame• Length of follow-up may be shorter than time horizon of CEA

(can be partially addressed through modeling)• Study design

• Observational studies may contain selection bias, confounding• Clinical trials can have differential loss to follow-up, frequently

unblinded which can induce bias, varying quality• Effectiveness vs. efficacy

• Estimates of MC uptake from an RCT may not indicate real world intervention performance (addressed by obtaining real world estimates of intervention uptake)

• Costs may also be different in the real world (can separate out intervention costs)

Important to recognize limitations in data and vary uncertain parameters in sensitivity analysis

Research Objectives• Generation of new knowledge • Hypothesis or research questions• generally short• Example:▫ determine the impact of sheep ranching on the wild

puma population in Peru▫ identify the needs of the farmers in preventing

loss of sheep due to puma predation▫ formulate ranching guidelines to meet the needs of

the farmer and the wild puma

Approach: The “How”

Approach

• Usually, this is the area allotted the most points

• Write this section first

Approach

• Often the most detailed and lengthy section• What specific activities will allow you to meet

your objectives• Task oriented, specific, detailed• Essential that you demonstrate all the steps

necessary to complete project with each flowing logically from the previous to the next.

Questions for Approach• Walk the reader through

your project• Describe the activities as

they relate to the objectives• Develop a time line and/or

and organizational chart

• How will the activities be conducted?

• When?• How long?• Who?• Where?• What facilities?

Approach

• If methodology is new or unique explain why it is better than that previously used

• Specify research design and why it was chosen.

• Include descriptions of variables and their relationships.

• Define all important terms

• Provide descriptions of data sources including subjects, how they will be selected, the size of subject pool, and the size of the sample.

• Describe all procedures• Include pilot instruments

and data when possible• Step-by-step work plan

Approach sections

• Overview of Research Design and Methods• Study site• Health economic aim▫ Overall goal▫ Modeling Model design Data sources, parameterization, validation,

assumptions Model outcomes

▫ Costing approach▫ Estimating cost-effectiveness

Approach

• Overview of Research Design and Methods for all aims

• Show that the aims are linked

• Study site▫ Include monthly income▫ Experience with conducting health economic analyses

Health economic aim

• Overall goal for health economic aim• …

Health economic aim

• Overall goal for health economic aim• We aim to provide estimates of impact (change

in HIV incidence) and cost (total costs and cost-effectiveness) for use by public health decision-makers to inform HIV treatment and prevention policies.

Modeling

• Model design▫ Compartmental vs. stochastic

• Data sources▫ Clinical trial, observational study, literature▫ Demographic and behavioral data from the study

• Parameterization▫ Existing data sources

• Validation▫ Independent data set

• Assumptions▫ Expected impact on results

• Model outcomes▫ Health units